On average, it took almost five days before facilities across both health authorities realised that the disease had in fact spread beyond their first infected worker and they belatedly imposed outbreak lockdowns.

The worst failure under the policy occurred at East Vancouver’s Little Mountain Place care home, where 41 people died in British Columbia’s deadliest outbreak.

That outbreak began to unfold just 11 days after the new provincewide protocols were introduced.

But a string of tragedies followed as dozens of other homes also delayed outbreak status, the FOI documents about the strategy show.

Long-term care homes have been hotspots for Covid-19 outbreaks across North America, due to their settings and the vulnerability of residents. However, the Post investigation suggests how obscure policies and practices might also have been at play when the second wave of the pandemic swept over British Columbia, a Canadian province that had drawn international praise for coping relatively well with the first wave last spring.

Rose Wong, a regular visitor to Little Mountain Place, where she would help feed her elderly Cantonese-speaking mother, had never heard of “enhanced surveillance and precautions” (ESP) before she received an email from the home on November 20.

The facility, which catered to a mostly Asian clientele, notified her and other residents’ relatives that a worker had caught Covid-19 – yet because VCH experts had judged the case low-risk, an outbreak would not be declared, in accordance with the new protocols.

Vancouver coronavirus tragedy: Sick carers tried to ‘push through’ symptoms

To Wong’s surprise, social visitation, common-area meals, group recreation and resident transfers were all being allowed to proceed. Mass testing at the facility would not take place.

The next day, Wong arrived at Little Mountain Place with a sense of trepidation.

The accountant had her doubts, but “they claimed they were going to be very strict. So I have to go by their word and trust them, right?” she asked. And her mother, Cui Chan Wong, a native of Taishan, China, who had lived at Little Mountain Place since 2017, still needed to be fed.

Wong’s next trip to see her mother would not take place for another five weeks, on December 27, as a full-blown outbreak raged through the care home. Cui, 73, was on her deathbed from the disease. Clad from head to toe in PPE gear, Wong said her goodbyes.

Two days after the detection of the “low risk” staff case, a Little Mountain resident also tested positive. It was only then that the facility went into an outbreak lockdown and conducted full-facility testing. Multiple staff and residents were immediately found to be infected.

The virus worked at a dreadful pace. Forty-one residents, including Cui, died in just six weeks. By the time the outbreak was done, 99 out of 114 residents, as well as 72 staff, had been infected.

But the outcome at Little Mountain Place was no isolated failure.

At South Vancouver’s German Canadian Care Home, a staff infection was detected on November 18, but the outbreak was not declared for another eight days. Sixty-one residents and 54 staff became infected, with 25 residents dying.

On December 19, a worker tested positive at Surrey’s Hilton Villa Seniors Community, but the outbreak declaration was not made until three days later. Twenty-four residents died, out of 76 who became infected along with 47 staff.

And at Royal City Manor in New Westminster, outbreak protocols were not introduced until nine days after a worker tested positive on Christmas. When the outbreak was over on March 5, 28 residents were dead, out of 102 who were infected along with 31 staff.

Wong is angry about the fate of her mother, and wonders if things would have turned out differently had outbreak measures been imposed at Little Mountain Place as soon as the first worker was found to be infected.

“They should have declared an outbreak on the 20th. They should have. But ‘precautions’? Then they wait to declare an outbreak? Then it’s 90 per cent infected? It doesn’t make sense,” she said.

Bernadette Cheung lost her grandmother to Covid-19 at Little Mountain Place in December. Yuet Wan was a “bubbly, friendly” Hong Kong immigrant, aged 94.

Cheung, a financial accountant, said she could not understand the decision that the first staff infection was low risk.

It was, she said, “a clearly incorrect assessment”.

‘I said, what do you mean, enhanced surveillance?’

Wong and Cheung are not the only ones with questions about the enhanced surveillance/monitoring strategy.

British Columbia’s Seniors Advocate Isobel Mackenzie said she would investigate the strategy, including its deployment at Little Mountain Place, as her office reviews how the province’s care homes have handled the pandemic.

As of April 24, 988 residents of BC care facilities have died of Covid-19 during the outbreak, accounting for about two-thirds of the province’s total death toll, although widespread vaccination has recently seen the care home crisis tail off and restrictions eased.

After Covid-19 tragedy, boss quits Vancouver care home for Chinese elders

Mackenzie, who has a watchdog role in her government position, described her shock at discovering that VCH homes were not automatically declaring outbreaks and were instead letting visits and group activities continue after a staff member had contracted Covid-19.

“Someone in Vancouver Coastal told me ‘well, [this is] what we do’. I went ‘what?’” she said, describing a conversation late last year with a VCH employee she did not want to identify. “I said, ‘what do you mean, enhanced surveillance?’”

Mackenzie said she went to the BC Health Ministry to “communicate my concern” about a policy that “clearly raises some questions”.

The response was a nonplussed “oh yeah, I think we heard something about that”, Mackenzie said.

Mackenzie suggested that the delay between the detection of the first staff infection at Little Mountain Place on November 20 and the declaration of an outbreak on November 22 could be crucial. “My question would be ‘during those two days, what did we do, or not do?’,” she said.

The FOI documents show that even longer delays between the detection of an infected employee and the introduction of outbreak protocols were the norm in dozens of care homes under the enhanced surveillance/monitoring system. They include some of the deadliest outbreaks in British Columbia.

On average, Vancouver care homes that declared outbreaks while already under enhanced surveillance/monitoring took 4.7 days after detecting their first staff infection to do so.

The delays were substantially longer in VCH compared to Fraser Health facilities and by almost every metric, the outbreaks were worse in VCH facilities.

That may reflect the fact that the two authorities took very different approaches to the strategy.

Care homes across the province all received new recommendations from the BC Centre for Disease Control and Ministry of Health on November 9 under the same broad terms: a single “low risk” infection of a staff member should not trigger an outbreak declaration if there was no evidence of transmission at the site, and it should instead result in a two-week status of enhanced surveillance/monitoring.

Although outbreak declarations on the basis of a single staff infection had been a matter of discretion for medical health officers since June 2020, in practice the November 9 guidance represented a major policy shift.

In a bulletin issued to care homes, VCH listed measures which “are not required during enhanced surveillance and precautions”, underlining the word “not”.

“Admissions, readmissions, or transfers do not need to be restricted … Visits by family members and companions do not need to be restricted … Non-essential services and group activities (including meals in common areas) do not need to be suspended,” said the bulletin.

“Asymptomatic screening tests for residents and staff should only be implemented under direction of the MHO [medical health officer],” the bulletin added. “Notification of all residents, families, staff and other service providers” about the initial infection “is not required”, it said.

Fraser Health took a stricter approach.

It told care homes in a bulletin that while full outbreak protocols would not be imposed under enhanced monitoring, they should “actively screen residents/tenants and staff”, as well as stop all group activities, social visits, admissions and transfers in the affected unit.

Terry Lake, the chief executive of the BC Care Providers Association, said he had repeatedly raised concerns about the disparate rules governing the industry to BC’s Health Ministry.

“These health authorities are large organisations and it’s not surprising when there is some breakdown in communication. But to have policies that are so different is confusing, ” he said. “It leads to a breakdown of trust, when you have people in one health authority saying one thing and people in another saying the opposite.”

Operators had pressed for clarity, and wanted to know why rules were contradictory, Lake said.

The FOI information covers November 9 to January 26 for VCH, and one month longer, November 9 to February 26, for Fraser Health, since that request was lodged later. The Post compared the FOI data to publicly available information about the outcomes of the outbreaks in question.

Minimal risk, said Vancouver home for Chinese elders. But Covid-19 killed 41

VCH homes took an average of 7.1 days to detect the second infection that triggered full outbreak status, compared to 3.9 days in Fraser Health; an average of 21 people per facility were infected in Fraser Health, compared to 37 in VCH; and twice as many residents died on average in the VCH outbreaks, 7.4 versus 3.7 in Fraser Health (although that is mostly attributable to VCH’s Little Mountain and German Canadian outbreaks).

There were 10 outbreaks at VCH care homes already under “enhanced surveillance and precautions” (ESP) status, infecting 366 residents and staff, with 74 residents dying. There were 32 outbreaks at Fraser Health homes under enhanced monitoring that infected 674 people, with 118 residents dying.

In addition to Fraser Health’s data covering a month longer period than VCH’s, Fraser Health oversees a population about 50 per cent greater than VCH’s and has been harder hit by Covid-19 in the broader community.

It is impossible to say for certain how the outbreaks might have been mitigated had the 42 Vancouver facilities declared them as soon as their first staff infections were detected.

But the 1,040 infections in those facilities were a major contributor to the devastating second wave of the pandemic in BC care homes.

They accounted for at least 25.1 per cent of all care home infections in British Columbia from November 9 to February 26, and 25.3 per cent of care home deaths. The true toll is likely higher, since the figures exclude a month of VCH data.

Misleading claims from top health officials

Dr Bonnie Henry, British Columbia’s provincial health officer, has repeatedly depicted discrepancies in the handling of outbreaks in different care homes in Vancouver as reflecting on-the-ground discretion by medical health officers.

But the Post’s investigation showed that contradictions in the advice given by VCH and Fraser Health were written – and substantial.

In the case of Little Mountain Place, both Henry and Dr Penny Ballem, board chair of VCH, have also misleadingly insisted the outbreak started with a resident, not a worker.

“Little Mountain, for certain, I can guarantee you, was declared an outbreak with the first case that was identified there, which was a resident,” said Ballem at a news conference on January 13, pushing back against reports about the role of workers spreading the disease.

On January 7 the Post reported on a leaked Zoom briefing by a VCH medical officer, who said that infected workers had likely spread Covid-19 at Little Mountain Place when they tried to “push through” their symptoms.

Ballem’s rebuttal was only true in the most technical sense: although a worker was in fact the first with a diagnosis of Covid-19 at Little Mountain Place on November 20, it was not considered the first case of the outbreak – because VCH’s officers decided not to declare one under the new protocols.

Henry tried to clarify at the same news conference, saying that “yes, the first case was identified as a resident. There was, I understand, a staff member who was not felt to have an exposure in the facility”.

VCH has since told the Post that “it is possible that the [resident] case which later tested positive was linked to this initial [staff] case or to other cases not previously diagnosed at that time”.

On April 1, Michelle Preston, VCH regional director of patient care, wrote to Bernadette Cheung and similarly told her: “Noting that a large number of cases were diagnosed in the initial round of screening tests, it is possible that COVID-19 transmission was ongoing in the facility before the initial positive case was diagnosed.”

VCH would not say how many people tested positive in the first round of full-facility testing at Little Mountain Place that occurred after the November 22 outbreak declaration, except that it was “a number of residents and staff”.

Mackenzie said the speed of Covid-19’s spread – and particularly that of new variants of the virus – meant time was of the essence. “This virus, your reaction needs to be within the hour – not even ‘within hours’,” she said.

By failing to mass-test Little Mountain Place immediately on November 20 – a protocol that would have automatically kicked in had an outbreak been declared – “clearly they missed a bunch of people in those 48 hours”, Mackenzie said.

Before the release of the FOI documents, both VCH and Fraser Health defended the use of enhanced surveillance/monitoring instead of outbreak declarations, even while resisting requests for data about the new protocols’ implementation.

VCH said that outbreak precautions “present challenges and harms for both residents and families, including limited visitation and limited resident movement throughout the long-term care home”.

“The implementation of enhanced surveillance precautions enables us to allow the families of residents to continue to visit their loved ones, with enhanced safety precautions, which is important for the health and mental well-being of residents,” a spokeswoman said.

Declaring outbreaks every time a worker fell ill was an unnecessary drain on resources, VCH also suggested.

“Most ESP declarations have not gone on to become outbreaks – that is, no further cases are diagnosed,” the spokeswoman said. “Managing these scenarios under ESP has allowed us to apply a full outbreak response to declared outbreaks, which would not be possible if all of our many one-staff scenarios were declared to be outbreaks.”

As of January 26, there had been a total of 57 ESP declarations in VCH facilities, of which 39 were in long-term care homes and the rest in hospitals or retirement homes; all except one of the 11 full outbreaks at those facilities occurred in long-term care; details of an outbreak at Vancouver General Hospital that also involved ESP status were not provided.

VCH only provided the final version of its FOI response last week, after earlier versions of the material contained obvious errors. For instance, three separate dates were provided for the start of enhanced surveillance at Little Mountain Place. The Post had lodged the FOI request on January 26.

A Fraser Health spokeswoman, meanwhile, said that enhanced monitoring was a strategy “in alignment with provincial guidance”. But she would not say how many times the status had been declared by the authority.

“Since the start of the pandemic, we have actively examined our approach to COVID-19 in long-term care and assisted living settings and have since learned a great deal about the virus,” she said.

Although less than full outbreak measures, enhanced monitoring still involved restricting visitors, as well as staff and resident movements within a facility. Residents and families were also notified, the spokeswoman said.

However, there have been mistakes in the way Fraser Health communicated its enhanced monitoring policy to care homes.

As recently as February, Fraser Health’s COVID-19 Resource Toolkit – its master policy document for long-term care and assisted living facilities – directed that: “A single lab-confirmed COVID-19 case IS considered an outbreak in the facility unless otherwise directed by the Medical Health Officer.”

This capitalised directive in a document updated on January 28 directly contradicted the bulletin issued by Fraser Health on December 17, which said: “When there is a single, low-risk case of COVID-19 with no evidence of transmission at a site (i.e. a COVID-19 exposure), the Medical Health Officer will not declare an outbreak and the facility will be placed on enhanced monitoring.”

The Toolkit was wrong, said the Fraser Health spokeswoman; it was corrected by March 4.

‘They kept allowing visitors. That seems crazy’

Relatives of those who died at Little Mountain Place are haunted by the decision not to impose outbreak precautions on November 20.

“When they knew, why didn’t they declare it? Why didn’t they take it more seriously then?” said Rose Wong.

Wong is particularly concerned that meals continued to be served in common areas before the outbreak declaration, since every resident of Little Mountain had their own room.

“If there’s ‘enhanced surveillance’ they shouldn’t have been letting anyone eat together in the lunch rooms. They should have been eating in their own rooms … Why didn’t they do that, when they could have done social distancing?” she said.

Writing on behalf of several families, Yuet Wan’s granddaughter Bernadette Cheung complained to the BC Ministry of Health in January about Little Mountain’s “flawed” handling of the outbreak.

“The continuation of social activities in the early days of the outbreak represents complete negligence of the serious nature of an infectious disease,” Cheung wrote.

Cheung said in an interview that she could not let go of her belief that delaying outbreak protocols was partly to blame for the disaster that claimed her grandmother’s life.

“I keep going back over it, and there was this lack of urgency overall,” she said. “They kept allowing visitors. That seems crazy.”